Tuesday, August 28, 2018

Children with autism spectrum disorder (ASD) frequently have co-occurring (comorbid) psychiatric conditions, with estimates
as high as 70 to 84 percent. A Comorbid
disorder is defined as a disorder that co-exists or co-occurs with another
diagnosis so that both share a primary focus of clinical and educational
attention. Research indicates that autistic children and youth have a high risk for
meeting criteria for other disorders, such as mood and anxiety disorders, attention deficit/hyperactivity disorder (ADHD), and disruptive behavior disorders, all which contribute to overall impairment.

Internalizing Problems

Studies have consistently reported an association between ASD and internalizing symptoms, in particular, anxiety and depression. A bidirectional association has been identified between internalizing disorders and autistic symptoms. For example, both a higher prevalence of anxiety disorders has been found in ASD and a higher rate of autistic traits has been reported in youth with mood and anxiety disorders. Autistic individuals also display more social anxiety symptoms compared to typical individuals, even if these symptoms were clinically overlapping with the characteristic social problems of ASD. In addition, there is some evidence to suggest that adolescents and young adults with ASD show a higher prevalence of bipolar disorders as compared to controls.

Depression is one of the most common comorbid conditions observed in individuals with ASD, particularly higher functioning youth. A study of psychiatric comorbidity in young autistic adults revealed that 70% had experienced at least one episode of major depression and 50% reported recurrent major depression. Although another documented association is with obsessive-compulsive disorder (OCD), it is difficult to determine whether observed obsessive-repetitive behaviors are an expression of a separate, comorbid OCD, or an integral part of the core diagnostic features of ASD (i. e., restricted, repetitive patterns of behavior, interests, or activities).

Externalizing Problems

An association between ASD and attention-deficit/hyperactivity disorder (ADHD) and other externalizing problems (i. e., oppositional defiant disorder) have been reported. Studies have found that children with ASD in clinical settings present with co-occurring symptoms of ADHD with rates ranging between 37% and 85%. Although there continues to a debate about ADHD comorbidity in ASD, research, practice and theoretical models suggest that co-occurrence between these conditions is relevant and occurs frequently. For example, case studies suggest that ADHD is a relatively common initial diagnosis in young autistic children. It is also important to note that a significant change in the DSM-5 is removal of the DSM-IV-TR hierarchical rules prohibiting the concurrent diagnosis of ASD and ADHD. When the criteria are met for both disorders, both diagnoses are given.

Other Comorbidities

Tourette Syndrome (TS) and other tic disorders have been found to be a comorbid condition in many children with ASD. A Swedish study showed that 20% of all school-age children with ASD met the full criteria for TS. There also appears to be a higher incidence of seizures in children with autism compared to the general population. The comorbidity of ASD and psychotic disorders has received some research attention. A study of children with ASD who were referred for psychotic behavior and given a diagnosis of schizophrenia showed that when psychotic behaviors were the presenting symptoms, depression and not schizophrenia, was the likely diagnosis. Thus, autistic individuals may present with characteristics that could lead to a misdiagnosis of schizophrenia and other psychotic disorders.

Implications

Children and youth with ASD frequently have comorbid conditions, with rates significantly higher than would be expected from the general population. The most common co-occurring diagnoses are anxiety and depression, attention problems, and disruptive behavior disorders. The core symptoms of ASD can often mask the symptoms of a comorbid condition. The current challenge for practitioners is to determine if the symptoms observed in ASD are part of the same dimension (i. e, the autism spectrum) or whether they represent another condition. Although various psychometric instruments, such as clinical interviews, self-report questionnaires and checklists, are widely used to assist in diagnosis, these tools are designed and standardized to identify symptoms in the general population, and may not be appropriate and valid for use with ASD. Likewise, their administration may be problematic in that autistic individuals may have difficulties in sustaining a reciprocal conversation, reporting events, and perspective taking. Nevertheless, comorbid problems should be assessed whenever significant behavioral issues (e.g., inattention, impulsivity, mood instability, anxiety, sleep disturbance, aggression) become evident or when major changes in behavior are reported. Co-occurring conditions should also be carefully investigated when severe or worsening symptoms are present that are not responding to intervention or treatment.

Friday, August 17, 2018

Education has been shown
to be among the most effective intervention/treatment for children with autism spectrum
disorder (ASD). The most recent reauthorization of the Individuals with
Disabilities Education Act (IDEA 2004) entitles all students with
disabilities to a free appropriate public education (FAPE). In fact, the
National Research Council (2001) recommends that all children identified with
ASD, regardless of severity, be made eligible for special educational services
under the IDEA category of autism. FAPE
encompasses both procedural safeguards and the student’s individualized education
program or plan (IEP). The IEP is the cornerstone for the education of a child with
ASD. When a student is determined eligible for special education services, an
IEP planning team is formed to develop the IEP and subsequently determine
placement. Parents, teachers and
support professionals play a key role in the development, implementation, and
evaluation of the child’s IEP. All share the responsibility for monitoring the
student’s progress toward meeting the plan's specific academic, social, and behavioral
goals and objectives.

Although the type and intensity of services will
vary, depending on the student’s age, cognitive and language levels, behavioral
needs and family priorities, the IEP should address all areas in which a child
needs educational assistance. These include academic and non-academic goals if
the services will provide an educational benefit for the student. All areas of
projected need are incorporated in the IEP, together with the specific setting
in which the services will be provided and the professionals who will provide
the service. School districts should ensure that the IEP process follows
the procedural requirements of IDEA. This includes actively involving parents
in the IEP process and adhering to the time frame requirements for assessment
and developing and implementing the student’s IEP. Moreover, parents must
be notified of their due process rights. It’s important to recognize
that parent-professional communication and collaboration are key
components for making educational and program decisions.

The content of an IEP
should include the following (Individuals with Disabilities Education
Improvement Act, 2004):

The IEP should be based on
the child’s unique pattern of strengths and weaknesses. Goals for a child with
ASD commonly include the areas of communication, social behavior, adaptive
skills, challenging behavior, and academic and functional skills. The IEP must
address appropriate instructional and curricular accommodations and
modifications, together with related services such as counseling, occupational
therapy, speech/language therapy, physical therapy and transportation needs.
Evidence-based instructional strategies should also be adopted to ensure that
the IEP is implemented appropriately.

A statement of the child's
present level of educational performance (both academic and nonacademic aspects
of his or her performance).

Specific goals and
objectives designed to provide the appropriate educational services. This
includes a statement of annual goals that the student may be expected to
reasonably meet during the coming academic year, together with a series of
measurable, intermediate objectives for each goal.

Appropriate objective
criteria, evaluation procedures and schedules for determining, at least
annually, whether the child is achieving the specific objectives detailed in
the IEP.

A description of all
specific special education and related services, including individualized
instruction and related supports and services to be provided (e.g., counseling,
occupational, physical, and speech/language therapy; transportation) and the
extent to which the child will participate in regular educational programs with
typical peers.

Accommodations should be
specifically documented in the IEP. Accommodations refer to the adjustments
made to ensure that the student has equal access to educational programming by
removing, to the extent, possible, barriers to successful classroom
performance. Adjustments may be made to (a) instructional methods, teaching
style, and curricular materials; (b) classroom and homework assignments; (c)
assessment tools and ways of responding; (d) time requirements; and (e)
environmental setting. Once accommodations are made, the student with special
needs is expected to meet the standards of all students.

The initiation date and
duration of each of the services to be provided (including extended school year
services).

If the student is 16 years
of age or older, the IEP must include a description of transitional services
(coordinated set of activities designed to assist the student in movement from
school to post-school activities).

School districts should
assure that progress monitoring of students with ASD is completed at specified
intervals by an interdisciplinary team of professionals who have a knowledge
base and experience in autism. This includes collecting evidence-based data to
document progress towards achieving IEP goals and to assess program
effectiveness. School districts should also provide on-going training and
education in ASD for both parents and professionals. Professionals who are
trained in specific methodology and techniques will be most effective in
providing the appropriate services and in modifying curriculum based upon the unique needs of the child.Adapted from Wilkinson, L. A. (2017). Best practice in special education. In L. A. Wilkinson, A best practice guide to assessment and intervention for autism spectrum disorder in schools(pp. 157-200). London: Jessica Kingsley Publishers.

National Research Council
(2001). Educating children with autism. Committee on Educational
Interventions for Children with Autism. C. Lord & J. P. McGee (Eds).
Division of Behavioral and Social Sciences and Education. Washington, DC: NationalAcademy Press.

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